The combative multitrauma patient: a protocol for prehospital management

Objective To describe the management of the combative trauma patient in the prehospital setting, and to suggest a protocol for management. Methods A retrospective, prehospital case series conducted in Israel among military medical teams over the course of nearly 2 years, between January 2000 and October 2002. We collected a case series of patients who became combative following traumatic injury. Following data collection, we summoned an expert panel and developed a protocol for physicians and paramedics upon encountering a combative trauma patient. Results Available data were found for 11 patients and these were included in the analysis. Most victims included in this study were injured under military or geographical circumstances mandating a long time interval from injury to definitive care, namely 114 min (range 38-225min). Five patients received intravenous ketamine, in three of which it was coadministered with midazolam. Sedation with ketamine given alone, or combined with other drugs, was effective in all five cases. In no case did a patient become more agitated after administration. No adverse effects were recorded by the prehospital caregivers. Conclusions In this article, an algorithmic approach to the treatment of the patient's agitation is outlined, using ketamine as the principal sedating agent, either alone or combined with midazolam. The combination of both drugs is suggested for the effective sedation of adult prehospital combative patient population.